Provider Demographics
NPI:1013575307
Name:GUNDERSEN, SHANNON LEE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:GUNDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEE
Other - Last Name:SCHAEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1440 E LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-0400
Mailing Address - Country:US
Mailing Address - Phone:724-328-1806
Mailing Address - Fax:
Practice Address - Street 1:3941 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2750
Practice Address - Country:US
Practice Address - Phone:480-787-5387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP15368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist